Errores de medicación: un reto para la anestesiología / Medication errors: a challenge for anesthesiology

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Note: development of ESS Bilbao's proton ion source: Ion Source Hydrogen positive.

The Ion Source Hydrogen positive is a 2.7 GHz off-resonance microwave discharge ion source. It uses four coils to generate an axial magnetic field in the plasma chamber around 0.1 T that exceeds the ECR resonance field. A new magnetic system was designed as a combination of the four coils and soft iron in order to increase the reliability of the source. The description of the simulations of the magnetic field and the comparison with the magnetic measurements are presented. Moreover, results of the initial commissioning of the source for extraction voltage until 50 kV will be reported.

Masa inguinal como forma de presentación de la enfermedad por arañazo de gato / Inguinal mass as presentation of cat-scratch disease

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[Intestinal parasitic infections and leishmaniasis in patients with HIV infection]. / Infecciones parasitarias intestinales y leishmaniosis en pacientes con infección por el VIH.

Intestinal parasite infections are very frequent in HIV patients with severe immunodeficiency (CD4 < 100/mm3) causing chronic diarrhea and malabsorption in the majority of cases. The most frequent microorganisms are microsporidia and Cryptosporidium parvum while Cyclospora cayetanensis and Isospora belli are more prevalent in subtropical and tropical areas and rare in industrialized areas. The diagnosis can be obtained by stool examination (differences in size and form of cysts), although microsporidia is frequently demonstrated by intestinal biopsy and/or duodenal aspirate. The treatment with cotrimoxazole for C. cayetanensis and I. belli is very effective and does not present any problems in the acute phase, however, due to a high percentage of relapses the treatment must be maintained while the patient is in a severe immunodeficiency state. E. intestinalis usually responds satisfactorily to albendazole while E. bieneusi is resistant to some drugs except in some cases (albendazole, atovaquone ad fumagillin). C parvum is also resistant to most medicaments but shows an adequate or partial clinical: response to paramomicine (< 50%). When there is no response, it is advised to administer octreotide since in half the cases the response is positive either total or partial. Nowadays with the use of protease inhibitors in the antiretroviral treatment a decrease in the incidence of these infections has been observed (microsporidia and C. parvum) even in the stools samples taken from the patients who had them before. As primary prophylaxis for C. parvum, it is better to avoid been exposed to the microorganism taking into account the 1997 preventive measures recommended by the USPHS/IDSA Prevention of Opportunistic Infections Working Group. The coinfection Leishmania-HIV is frequent in the mediterranean area. The most common specie is L. infantum. The incidence is most frequent in immunosuppressed patients (CD4 < 200 mm3) and in parenteral drug addicts. The symptomatology is similar to the one from immunocompetent patients, although in some cases it appears to be subclinical. A chronic development with relapses is frequent. The most effective diagnostic method for the finding of the parasites is thru bone marrow puncture and the culture in Novy-McNeal-Nicolle (NNN) medium. Serological tests have a low sensibility and the PCR is useful in asymptomatic cases, for therapeutical control and in relapses. The treatment is similar to that of immunocompetent patients, using primarily antimonials or amphotericine B (standard or lipid or liposomal forms). Relapses are very frequent, therefore, it is important to perform a secondary prophylaxis. However, no treatment has been completely effective. Mortality rate is high (approximately 25%) during the first month after diagnosis. This fact may be related to the severe immunodeficiency state and/or to the toxicity of the drugs used. The main priority for the future is to find a first line treatment with higher efficacy, decrease in relapses and a lower toxicity.

[Risk factors in stable coronary disease. Relationship with ischemic threshold and prognostic implications]. / Factores de riesgo en la enfermedad coronaria estable. Su relación con el umbral de isquemia e implicaciones pronósticas.

BACKGROUND: To assess the clinical evolution, in a 5-year follow-up, of the development of acute coronary syndromes, in patients with angina clinically stable, establishing its relationship with the ischemic threshold (IT) and the main modifiable cardiovascular risk factors. PATIENTS AND METHODS: 120 patients, 86 males (71%), with an age of 57 +/- 8 years, with stable angina. The presence of smoking, hypercholesterolemia, hypertension and diabetes mellitus was evaluated. We performed exercise testings (baseline and after vasodilator drugs) in the beginning, in order to characterize the IT (which was fixed in 72 patients and variable in 48). The later group underwent exercise testing each term during the first year of follow-up. Lesion at least of 70% in a main coronary vessel was required as inclusion criteria. The development of acute myocardial infarction (AMI), unstable angina pectoris and cardiac death was recorded. Cox's hazard function analysis and multivariant analysis were applied. RESULTS: 106 patients (88%) had one or more risk factors (40% hypertension, 43% hypercholesterolemia, 22% diabetes mellitus and 56% were smokers or ex-smokers). A significant association was shown between male gender and smoking and diabetes mellitus and female gender. 6 cardiac deaths, 8 AMI and 9 unstable angina were recorded. Within the 72 patients with fixed IT, 12.5% (9) suffered some acute syndrome. In the 48 with variable IT, in the 30 who continued in it, 20% (6) developed acute coronary pathology and in the 18 who modified their IT to fixed, the prevalence was 44.5% (8). Patients with modification of IT to fixed had a higher risk of acute coronary syndrome in the follow-up (p < 0.01) and the presence of hypertension and hypercholesterolemia allowed the prediction of modification of the IT. CONCLUSIONS: The prevalence of cardiovascular risk factors in the stable coronary artery disease is high (88%); male gender is associated smoking and female gender to diabetes mellitus. The presence of hypertension and hypercholesterolemia are associated to modification in the IT in patients with variable threshold, allowing the detection of a subgroup of high risk for the development of acute coronary pathology.

[The effect of antihypertensive therapy on left ventricular mass and diastolic filling in light and moderate hypertension]. / Efecto de la terapia antihipertensiva sobre la masa ventricular izquierda y el llenado diastólico en la hipertensión ligera a moderada.

BACKGROUND: To valorate the effect of four antihypertensive drugs on the regression of cardiac mass and diastolic function, by echocardiography-Doppler, in not treated hypertensive subjects. METHODS: 60 mild-moderate hypertensive subjects were studied randomized in four groups of 15 patients each one: enalapril (10-40 mg/d), atenolol (25-100 mg/d), verapamil-retard (120-240 mg/d), alphametildopa (250 mg/8h to 3 g/d). The active drug therapy phase was 6 months, performing echo-Doppler, evaluating posterior-wall and septal-wall thicknesses, ventricular mass index, ratio of early to atrial peak diastolic filling velocity (E/A), the first-third filling fraction and atrial filling fraction. RESULTS: The cardiac mass index decreased with the four drugs: with enalapril from 178 +/- 28 to 155 +/- 29 g/m2 (p < 0.05), with atenolol from 170 +/- 23 to 154 +/- 19 g/m2 (p < 0.05), with verapamil from 180 +/- 27 to 159 +/- 22 g/m2 (p < 0.05) and with alphametildopa from 176 +/- 30 to 142 +/- 22 g/m2 (p < 0.01). The E/A ratio and first-third filling fraction only improved in the atenolol subgroup, from 0.79 +/- 0.13 to 0.97 +/- 0.16 (p < 0.01) and from 36 +/- 5 to 44 +/- 9% (p < 0.01), decreasing atrial filling fraction from 37 +/- 6 to 30 +/- 8% (p < 0.01), without modifying with enalapril (0.74 +/- 0.14 to 0.76 +/- 0.20, 35 +/- 5% to 36 +/- 7%, 38 +/- 5 to 39 +/- 7%, p = NS), verapamil (0.69 +/- 0.12 to 0.74 +/- 0.17, 35 +/- 6% to 36 +/- 8% to 40 +/- 12%, p = NS) neither alphametildopa (0.72 +/- 0.14 to 0.71 +/- 0.21, 34 +/- 5% to 35 +/- 7%, 40 +/- 6% to 41 +/- 9%, p = NS). The heart rate decreased more with atenolol than with the other drugs (61 +/- 15 vs 71 +/- 12, p < 0.01). CONCLUSIONS: In hypertensive patients the decreasing of cardiac mass is not accompanied of improvement of the diastolic function except in patients treated with atenolol, probably due to bradycardia.

[Doppler analysis of mitral flow in mild to moderate hypertension]. / Análisis de la curva de flujo Doppler mitral en la hipertensión arterial leve a moderada.

We evaluate by Echo-Doppler the left ventricular relaxation disturbance produced by mild to moderate hypertension. It's a comparative study between 15 healthy and 40 patients with hypertension (diastolic blood pressure between 90-114 mmHg and/or systolic greater than 160 mmHg). Echocardiography was performed in all cases and diameters, thickness, volumes, ejection fraction, mass, transmitral flow by Doppler and cardiac output were evaluated . In hypertensive patients the septal and posterior wall thicknesses were significantly higher (1.39 +/- 0.2 cm vs 1.1 +/- 0.1, p less than 0.001 cm. and 1.26 +/- 0.12 cm vs 0.98 +/- 0.1 cm, p less than 0.001), and also the absolute mass and corrected according to corporal surface (339 +/- 58 g vs 203 +/- 44, p less than 0.001, and 185 +/- 34 g/m2 vs 115 +/- 16, p less than 0.001). In transmitral flow Doppler the higher isovolumetric period and lower diastolic filling in the first 1/3 (71 +/- 19 msec vs 53 +/- 20, p less than 0.05, and 35 +/- 5% vs 52 +/- 4%, p less than 0.001) are indicators of relaxation disturbance. A lower deceleration of early inflow and a higher deceleration time (265 +/- 98 cm/sec2/vs 454 +/- 139, p less than 0.001, and 226 +/- 38 msec vs 156 +/- 15, p less than 0.001) show compliance damage. The atrial filling was significantly higher in hypertensive patients (37 +/- 7% vs 20 +/- 8%, p less than 0.001). The E/A ratio, separate both groups but corrected by the age the signification was rather lower.(ABSTRACT TRUNCATED AT 250 WORDS)